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The aim of this study was to understand the quality of diet being consumed among families in Addis Ababa, and to what extent social stratification and perceptions of availability and affordability affect healthy food consumption. Data were collected from 5467 households in a face-to-face interview with mothers/caretakers and analyzed using mixed effect logistic regression models. All family food groups, except fish were perceived to be available by more than 90% of the participants. The food groups cereals/nuts/seeds, other vegetables, and legumes were considered highly affordable (80%) and were the most consumed (>75%). Households with the least educated mothers and those in the lowest wealth quintile had the lowest perception of affordability and also consumption. Consumption of foods rich in micronutrients and animal sources were significantly higher among households with higher perceived affordability, the highest wealth quintile, and with mothers who had better education. Households in Addis Ababa were generally seen to have a monotonous diet, despite the high perceived availability of different food groups within the food environment. There is a considerable difference in consumption of nutrient-rich foods across social strata, hence the cities food policies need to account for social differences in order to improve the nutritional status of the community.
A community-based cross-sectional study was carried out in the months of July–August, 2017 and January–February, 2018 in Addis Ababa, the capital city of Ethiopia. Addis Ababa has been experiencing a rapid increase in population size along with diminishing open public space [36]. The rapid expansion of residential areas to accommodate the increasing population size has led to the loss of highly fertile agricultural land and green spaces thereby reducing food production within and in the vicinity of the city [37]. This in turn, escalates the food prices and further jeopardizes the food and nutrition security of urban dwellers. Additionally, the city has one of the highest literacy rates in the country with 80% of its population having basic literacy level, and a high level of unemployment with 23.5% of the population in this urban area being unemployed [38,39]. The study used a multi-stage sampling procedure. All 116 woredas (districts) in the city were included in the study in each of the two rounds of survey: First round took place during the wet season and second round during the dry season to consider seasonal variations. Each district was further divided into roughly five equal geographical clusters and one cluster was then selected using simple random sampling. Subsequently, systematic random sampling was used to visit 60 households in each cluster to check for eligibility. All households with at least one under five-year-old child were invited to participate. Additional households were visited if there were less than 20 eligible households in the cluster. Households in which the mother/caregiver was not available to interview after 3 repeat visits were then declared unavailable and excluded from the study without replacement. The necessary data for the study were collected through face to face interviews with the mother/caregiver using a structured questionnaire. The questionnaires included sections on demographic and household characteristics, perceived availability and affordability of food groups, and family food consumption. The questionnaire comprised of standard measures as well as newly developed measures to assess the perceived affordability and availability; this was based upon literature and the research team’s expertise in this field. A photo gallery of common foods was used to help respondents understand the food groups. The questionnaires were initially developed in English and translated into Amharic language (the official language of Ethiopia) by a panel of translators. The questionnaires were pretested in households that were not included in the study for comprehension of concepts and language. Data were collected using tablets pre-programmed with the questionnaire. The data collectors were trained on the objective of the study, the content of the questionnaires, the sampling procedures, and the use of the tablets. The data collection was supervised daily by members of the research team and on-site support was given to the teams to ensure the study procedures were strictly observed. Data were received directly onto the data server at the Addis Continental Institute of Public Health and a data manager provided regular feedback on the quality of data. The age of the mothers was grouped into five categories: 15–24, 25–34, 35–44, and 45+, and their educational levels were summarized as: never attended/finished a grade, grade 1–4, grade 5–8, grade 9–12, and college. Marital status was categorized as currently married (in union) and currently not married (single). Wealth index was computed from multiple variables including ownership of house, type of housing unit, housing material (floor, roof, wall material), access to a separate toilet facility and clean drinking water, and assets (including bicycle, motorbike, car, cell-phone, radio, TV, refrigerator, bed, electric stove for making the local bread “Injera” and a saving account) [40]. Households were then divided into wealth quintiles (lowest, second, third, fourth, and highest) to indicate their relative economic status. For this study, a modified version of the women’s minimum dietary diversity indicator was used; it measures quality of diet, both in terms of energy and micronutrient adequacy [41] instead of using the usual household diet diversity measures which reflect more on the economic access and dietary energy [42]. This modified measure used in this study, hereafter referred to “family food groups”, has eleven food groups rather than 10 as in the usual measures. Based on the local consumption patterns; food groups “fish and meat” and “Vitamin A rich fruits and vegetables” were both split; while merging “legumes” with “nuts and seeds” groups since the latter is not commonly consumed in the study setting. Perceived availability of family food was measured using a photo gallery of common foods from each of the family food groups (11-family food groups). Mothers were asked whether any of the foods shown in the photo were available in the market. The response options were “Yes”, “No”, and “Don’t know”. Then, each food group was dichotomized as “available” if the responses were “yes” and “not available” if the responses were “no”. “Don’t know” responses were treated as missing. Perceived affordability of family food was assessed by asking the mother/caregiver, “How often can your family afford to consume any of these foods?” Response options were coded: “as often as wanted”, “a little less frequently than wanted”, and “much less frequently than wanted/not at all”. Perception of affordability was dichotomized as “affordable” if response was “as often as wanted” and “not affordable” for the other categories. Household food consumption was measured by a combination of two complimentary methods; first the mothers were asked to recall foods consumed by the family in the last 24 h. Then, the enumerator read and showed the photos of common foods by family food group whilst asking: “did any household member consume any of these foods in this photo in the last 24 h?” The response options included “yes”, “no”, and “don’t know”; the response category “don’t know” was treated as missing. Analysis was conducted using the statistical software program Stata version 15.0 [43]. Standard descriptive statistics were computed for outcome and explanatory variables including percentages and their respective confidence intervals for categorical variables as well as mean and standard deviation for continuous variables. Mixed effect logistic regression models were used to assess the bivariate and multivariable associations between the dependent variables’ family food consumption and the explanatory variables including perceived affordability, wealth quintiles, and maternal education. All models were adjusted for clustering at district level. p-values of <0.05 were considered as statistically significant. The variance of random effect value along with 95% confidence intervals (CI) and standard error (SE) computed to observe heterogeneity between districts. An additional intraclass correlation coefficient (ICC) was conducted to check variance at district level. Ethical approval for the EAT Addis study was obtained from the institutional review board of Addis Continental Institute of Public Health with reference number ACIPH/IRB/004/2015 and University of Gondar institutional review board reference number V/P/RCS/05/352/2019. Verbal informed consent was obtained from each of the participants after explaining the purpose of the study and addressing any questions. Permission to conduct the study was obtained from all sub-cities and district level health offices.
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